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Plan Type POS
Office Visit for Primary Doctor
Find Doctors
No charge, deductible does not apply
Office Visit for Specialist $40 copay, deductible does not apply
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible Individual: $1,500
Separate Prescription Drugs Deductible $400 per person (applies to Preferred Brand and Non-Preferred Brand drugs only)
Coinsurance None
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit Individual: $4,500
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Emergency Care Only. (out-of-network coverage available). Claims subject to review in accordance with contract terms. 
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No charge, deductible does not apply
Periodic OB-GYN Exam No charge, deductible does not apply
Well Baby Care No charge, deductible does not apply
Emergency and Urgent Care
Emergency Room $200 copay (waived if admitted)
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible $400 per person (applies to Preferred Brand and Non-Preferred Brand drugs only)
Mail Order Prescription Drugs N/A
Mail Order Supply Up to 34 day supply- non-maintenance drugs Up to 90 days supply- maintenance drugs
Outpatient Coverage
Outpatient Surgery $40 copay after deductible
Outpatient Lab/X-Ray No charge, deductible does not apply
Imaging (CT and PET scans, MRIs) N/A
Outpatient Mental Health N/A
Outpatient Substance Abuse N/A
Outpatient Rehabilitation Services (PT, OT, ST) N/A
Inpatient Coverage
Hospitalization $450/day copay after deductible
Skilled Nursing Facility N/A
Inpatient Mental Health N/A
Inpatient Substance Abuse N/A
Home Healthcare N/A
Maternity Coverage
Pre & Postnatal Office Visit $40 copay after deductible
Labor & Delivery Hospital Stay $450/day copay after deductible
Pediatric Services
Dental Checkup for Children N/A
Vision Screening for Children N/A
Eye Glasses for Children N/A
Major Dental Coverage (Pediatric) N/A
Additional Coverage
Chiropractic Coverage $40 copay, deductible does not apply (limited to 20 visits per benefit period)
Durable Medical Equipment N/A
Hospice N/A
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $2,500 Individual /$5,000 Family
Out-of-Network Annual Coinsurance 0%
Out-of-Network Annual Out-of-Pocket Limit $5,900 Individual/$11,800 Family
Additional Information
A.M. Best Rating NR-5pd as of 05/19/2010
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Summary of Benefits & Coverage (Not available)

The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Customer reviews

Important notices and disclaimers

  • The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • CareFirst BlueCross BlueShield - Preferred Provider Organization (PPO) Plans underwritten by Group Hospitalization and Medical Services, Inc.or CareFirst of Maryland, Inc.: BluePreferred HSA Bronze $3,500, BluePreferred HSA Silver $1,500, BluePreferred Gold $500 and BluePreferred Platinum $0.
  • CareFirst BlueCross BlueShield - Point of Service (POS) Plans underwritten by CareFirst BlueChoice Inc., for in-network benefits and by Group Hospitalization and Medical Services, Inc. or CareFirst of Maryland, Inc. for out-of-network benefits: BlueChoice Plus Bronze $5,500, BlueChoice Plus Silver $2,500, HealthyBlue Gold $1,500 and HealthyBlue Platinum $0.
  • CareFirst BlueCross BlueShield - Health Maintenance Organization (HMO) Plans underwritten by CareFirst BlueChoice Inc.: BlueChoice Young Adult $6,600, BlueChoice HSA Bronze $6,000, BlueChoice HSA Bronze $4,000, BlueChoice Silver $2,000, BlueChoice HSA Silver $1,300, BlueChoice Gold $1,000 and BlueChoice Gold $0.
  • CareFirst BlueCross BlueShield - Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc., serving MD excluding Montgomery and Prince George's Counties, and Group Hospitalization and Medical Services, Inc., serving VA, DC and Montgomery and Prince George's Counties in MD. CareFirst BlueChoice, Inc., an affiliate company, also offers health benefit products and services on this site.
  • CareFirst BlueCross BlueShield - CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association.® Registered trademark of the Blue Cross and Blue Shield Association. ® Registered trademark of CareFirst of Maryland, Inc.